Integrity, Perseverance, Tenacity
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Employment Case
DO I HAVE AN EMPLOYMENT CASE
Name
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Country
Phone
Email
Name of your current or former employer:
Your job title:
Approximate Annual compensation:
Were you fired?
Yes
No
If fired, when?
If not fired, do you think you are about to fired?
Yes
No
When
Were you given a reason for your termination/why you are about to be fired?
Yes
No
If so, what is the reason given by your employer?
Do you think the reason is true?
Yes
No
If not, what is the real reason?
Did you resign?
Yes
No
If yes, when?
If yes, why?
Have you been harassed or discriminated against because of your membership in a protected class (race, religion, creed, color, national origin, ancestory, physical disability, mental disability, medical condition, marital status, gender, gender identity,
Yes
No
If yes, please briefly describe the harassment/discrimination?
Who harassed/discriminated against you (identify name and job title)?
When was the last time that you were harassed/discriminated against?
Did anyone witness the harassment/discrimination?
Yes
No
If yes, who and what do you believe they witnessed:
Have you been retaliated against for (check one)
blowing the whistle on illegal conduct?
refusing to engage in illegal conduct?
complaining about discrimination/harassment?
engaging in protected activity (taking family or medical leave, taking time off to vote or serve on jury duty, etc...)?
If yes, please briefly describe the retaliation?
Who retaliated against you (identify name and job title)?
Please indicate any other facts that you believe are important. We need to know what your employer did to you, why they will say they did it to you, why you believe it is illegal, and what damage or loss you suffered because of what they did.
Verification
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